Step 4: The exploration of immediate suicide events
In this region, the interviewer focuses on, “What is this patient’s immediate suicidal intent?’’ As with previous regions, it remains important to remember that reflected intent (which might be revealed by nonverbal communications) may be a better indicator of real intent than what the patient states in his or her intent. The clinician explores any suicidal ideation, desire, and intent that the patient may be experiencing during the interview itself and also inquires whether the patient thinks he or she is likely to have further thoughts of suicide after leaving the office, ED, or inpatient unit, or gets off the phone following a crisis call. The region of immediate events also includes any appropriate safety planning. The focus of the exploration of immediate events is thus on the present and future (easily remembered as the region of Now/Next).
Exploring immediate desire (the intensity of the client’s pain and desire to die) and the client’s intent (the degree with which the client has decided to actually proceed with suicide) is clarified by discerning the relationship between the two, for they are not identical despite being intimately related. A patient could have intense pain with a strong desire to die yet have no intent as reflected by, “I could never do that to my children.” Conversely, over time, a patient’s pain could become so intense that it overrides his or her defenses that had prevented intent, resulting in a patient who impulsively acts.
A sound starting place is the question, “Right now, are you having any thoughts about wanting to kill yourself?” From this inquiry, a variety of questions can be used to further explore the patient’s desire to die, such as:
1. “How would you describe how bad the pain is for you in your divorce right now, ranging from ‘It’s sort of tough, but I can handle it okay’ to ‘If it doesn’t let up, I don’t know if I can go on’?”
2. “In the upcoming week, how will you handle your pain if it worsens?”
Questions such as the following can help delineate intent:
1. “I realize that you can’t know for sure, but what is your best guess as to how likely it is that you will try to kill yourself during the next week from highly unlikely to very likely?”
2. “What keeps you from killing yourself?”
It is important to explore the patient’s current level of hopelessness and to assess whether the patient is making productive plans for the future or is amenable to preparing concrete plans for dealing with current problems and stresses. Questions such as, “How does the future look to you?” “Do you feel hopeful about the future?” and “What things would make you feel more or less hopeful about the future?” are useful entrance points for this exploration. If not addressed in an earlier time frame, an exploration of reasons for living can be nicely introduced here with, “What things in your life make you want to go on living?”
The task of developing a safety plan is frequently facilitated by asking questions, such as, “What would you do later tonight or tomorrow if you began to have suicidal thoughts again?” From the patient’s answer, one can sometimes better surmise how serious the patient is about ensuring his safety. Such a question also provides a chance for the joint brainstorming of plans to handle the reemergence of suicidal ideation. Sound safety planning often includes a series of steps that the patient will take to transform and/or control suicidal ideation if it should arise. Such planning could begin with something as simple as taking a warm shower or listening to soothing music and end with calling a crisis line or contacting a cab to return to the hospital if out on a pass.
Such questioning leads the clinician to the complex issue of whether or not “safety contracting” as opposed to “safety planning” may be of use with any specific patient. In my opinion, each patient is unique in this regard.
Safety contracting has become somewhat of a controversial topic. To understand its use in a practical sense, it is important to remember that in addition to the fact that it may metacommunicate caring and concern on the part of the interviewer, there are 2 main reasons or applications for safety contracting: (1) as a method of deterrence and (2) as a sensitive means of suicide assessment. These applications are radically different and their pros and cons are equally radically different. The intensity of the debate, in my opinion, is generated because most of what is “debated” has to deal primarily with its application as a deterrent, which has many limitations.